• Your insurance card
  • Physician referral forms, if required by insurance
  • List of prescriptions and/or over-the-counter medication, including dose and frequency (we invite you to print and fill out a PDF version of our Medication Log form)
  • Information about your medical and surgical history
  • Recent x-ray reports or relevant records

Patient Forms

Please print out and complete the following patient forms and bring them with you to your appointment:
[PDF help]

New Patient Information

Patient History Form
Please complete only the sections of the form marked with yellow headers

Patient Medication Log

Patient Pharmacy Information Sheet

Authorization to Release or Use Information

Insurance and Payment Information

Santiago Martinez, M.D., is a provider for Medicare and most major insurance plans, and provides insurance billing. You are responsible for charges that are not covered by your insurance, at the time of your appointment.

Your insurance company may require a co-payment at the time of your appointment. When necessary, our staff will work with patients to set up a payment plan.

If you have questions regarding billing or which insurance plans we accept, please call us at the phone number below. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Affiliated Hospitals

  • Florida Hospital
  • Orlando Regional Medical Center
  • Winter Park Hospital
  • South Lake Hospital
  • Health Central